Provider Demographics
NPI:1477270254
Name:LACY-POLK, DONELL LAMAR
Entity Type:Individual
Prefix:
First Name:DONELL
Middle Name:LAMAR
Last Name:LACY-POLK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3285
Mailing Address - Country:US
Mailing Address - Phone:907-312-5564
Mailing Address - Fax:
Practice Address - Street 1:1319 E OSCEOLA PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1606
Practice Address - Country:US
Practice Address - Phone:689-837-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty